Autism & psychosis: misattributions

Psychosis refers to a condition of the mind—or a collection of symptoms that affect the mind—that makes it difficult to determine what is real and what isn’t; it constitutes some loss of contact with reality. In part 1 of autism & psychosis, we explained more about what psychosis is and its association with autism.

But what if autistic traits are being confused with a break from reality? In this article, we will go into how psychosis can be misattributed to autism.

When a diagnosis of psychosis is actually autism

While psychosis is a common experience for autistics, there are also frequent experiences within the autistic community of misdiagnoses. Research finds that there are many cases in which individuals diagnosed with psychosis-related conditions are actually autistic!^[1]Varieties of misdiagnosis in ASD: an illustrative case series (Schalkwyk et al., 2015) In these cases, individuals are diagnosed with psychosis or a psychosis-related condition instead of autism. Here are some theories as to why this happens:

Delusions

Many autistics do experience delusions. However, it seems likely that in many cases, what are thought to be “delusions” to an outsider may simply be a result of our neurodivergent (and therefore non-normative) experiences. The double empathy problem may explain why our lived experiences may seem “delusional” to a neurotypical individual.^[2]Theory of mind, causal attribution and paranoia in Asperger syndrome (Blackshaw et al., 2001)

For example, autistics are often detail-oriented and very good at spotting patterns. This leads many autistics to report noticing things that neurotypicals don’t. For me personally, I sometimes will have an intuition about something which turns out to be right down the line even though I can’t explain it in the moment. Looking back, I’m usually able to recognize that it’s because I was spotting subtle patterns that others could not perceive. Unfortunately, I’ve been called “crazy” and even “delusional” at times for voicing these intuitions because the neurotypicals around me thought that I wasn’t making any sense.

I can see how for other autistics, pointing out an intuition that makes no sense to a neurotypical clinician can be misclassified as psychosis. A neurotypical individual who isn’t able to empathize with our experiences may try to explain why we are “delusional” based on a completely different way of processing information.

Delusions may even be less common in autism because of our ability to spot details, making us less susceptible to falling for illusions. In contrast, individuals who experience psychosis have been shown to be more susceptible to falling for illusions.^[3]Autism and psychosis as diametrical disorders of embodiment (Crespi & Dinsdale, 2019 For example, autistics usually don’t fall for body transfer illusions, whereas those with psychosis-related conditions do.

We can also differentiate between psychotic delusions and autistic “delusions” based on differences in social communication styles. For example, if we misinterpret a social interaction, this may be misclassified as a delusion instead of a misunderstanding of neurotypical social cues.^[4]High-functioning autism patients share similar but more severe impairments in verbal theory of mind than schizophrenia patients (Tin et al., 2018)^[5]Recognizing Psychosis in Autism Spectrum Disorder (Ribolsi et al., 2022) In this case, if we are given the information we need to understand the situation, our “delusions” will dissipate. In contrast, someone experiencing psychosis is usually unable to integrate this new information and change their mindset.

Research also finds that both autistics and schizophrenics tend to have delusions related to feeling socially discriminated against, judged, and controlled by others.^[6]The fear of others: a pilot study of social anxiety processes in paranoia (Newman Taylor & Stopa, 2013)^[7]Theory of mind, causal attribution and paranoia in Asperger syndrome (Blackshaw et al., 2001)^[8]Recognizing Psychosis in Autism Spectrum Disorder (Ribolsi et al., 2022) However, I would argue that this “paranoia” is likely rooted in very real past experiences of discrimination. We know that autistics experience high rates of bullying and discrimination. Therefore, these fears may be rational, rather than delusional, based on our lived experiences.

Hallucinations

Given that autistics often have differences in sensory processing, these characteristics can be misclassified as psychosis.^[9]Recognizing Psychosis in Autism Spectrum Disorder (Ribolsi et al., 2022)^[10]Prevalence of Asperger syndrome among patients of an early intervention in psychosis team (Davidson et al., 2014)^[11]Varieties of misdiagnosis in ASD: an illustrative case series (Schalkwyk et al., 2015)^[12]Recognizing Psychosis in Autism Spectrum Disorder (Ribolsi et al., 2022) For example, it is common for autistics to hear sounds that neurotypicals cannot perceive.^[13]Autistic traits and abnormal sensory experiences in adults (Horder et al., 2014) I’ve had the experience where I can hear the electricity in the walls but when I bring this up with neurotypicals in the room, they don’t believe me. In a clinical setting, this can be assumed to be psychosis because, to a neurotypical, it may appear like we are hallucinating and hearing sounds that do not exist.^[14]Autistic traits and abnormal sensory experiences in adults (Horder et al., 2014)^[15]Adults with autism spectrum conditions experience increased levels of anomalous perception (Milne et al., 2017) Both autistic individuals with heightened sensory perception and individuals who experience psychosis describe these sensory experiences to be intrusive and stressful.^[16]Adults with autism spectrum conditions experience increased levels of anomalous perception (Milne et al., 2017)^[17]Recognizing Psychosis in Autism Spectrum Disorder (Ribolsi et al., 2022) Therefore, when these sensory experiences cause us distress, it may be even more likely that we may be misdiagnosed with psychosis.

For late-diagnosed autistics, we may have even been told from a young age that our heightened sensory perceptions were hallucinations.^[18]Varieties of misdiagnosis in ASD: an illustrative case series (Schalkwyk et al., 2015) Some of us have even been hospitalized and medicated in an attempt to treat this “psychosis.” Instead, what we needed was to learn about autism and heightened sensory processing. Findings have even shown that when antipsychotics are given to autistics experiencing such “hallucinations,” the treatments do not help. In contrast, support for anxiety and for managing stressful situations made a difference.^[19]Varieties of misdiagnosis in ASD: an illustrative case series (Schalkwyk et al., 2015)^[20]‘All that glitters is not gold’: misdiagnosis of psychosis in pervasive developmental disorders—a case series (Dossetor, 2007)^[21]Recognizing Psychosis in Autism Spectrum Disorder (Ribolsi et al., 2022)

One older case study found that interoception difficulties and communication differences in autism can also make it seem like we are experiencing psychosis.^[22]‘All that glitters is not gold’: misdiagnosis of psychosis in pervasive developmental disorders—a case series (Dossetor, 2007) In this case, the autistic individual struggled to differentiate between their internal thoughts and the external environment. When they were stressed, their thoughts became intrusive and distressing. However, because they struggled with interception and struggled to explain what they were going through, the clinician thought that they were describing auditory hallucinations.

Social interaction differences

Both autism and psychosis are associated with differences in social interaction and communication.^[23]What is the prevalence of autism spectrum disorder and ASD traits in psychosis? A systematic review (Kindaid et al., 2017)^[24]Recognizing Psychosis in Autism Spectrum Disorder (Ribolsi et al., 2022)^[25]Autism Spectrum Disorder and Clinical High Risk for Psychosis: A Systematic Review and Meta-analysis (Vasquerizo-Serrano et al., 2022) However, when looked at more closely, we can differentiate between the social communication traits in autism versus psychosis.^[26]Autistic Symptoms and Social Functioning in Psychosis: A Network Approach (Isvoranu et al., 2022)^[27]Recognizing Psychosis in Autism Spectrum Disorder (Ribolsi et al., 2022) For example, catatonia, a common characteristic in psychotic conditions, can be confused with autistic shutdowns, times when we are non-speaking, and times when we do not display overt non-verbal communication.^[28]What is the prevalence of autism spectrum disorder and ASD traits in psychosis? A systematic review (Kindaid et al., 2017) From my view, it seems likely that these two neurodivergent populations are often lumped together just because their social behaviours are different (and incomprehensible) to neurotypicals.^[29]The association between autism and schizophrenia spectrum disorders: a review of eight alternate models of co-occurrence (Chisholm et al., 2015)

Age of onset

Another differentiating factor is the age of onset of psychosis. We have autistic traits from birth onwards. In contrast, conditions characterized by psychosis, like schizophrenia, usually emerge in late adolescence and early adulthood.^[30]Autistic Symptoms in Schizophrenia Spectrum Disorders: A Systematic Review and Meta-Analysis (Crescenzo et al., 2019)^[31]Recognizing Psychosis in Autism Spectrum Disorder (Ribolsi et al., 2022) If an individual has been identified as autistic early on, and then grows to develop psychotic symptoms which cannot be explained by autistic traits, then it is much more likely that a co-diagnosis of autism and psychosis makes sense.^[32]Diagnostic Characteristics of Psychosis and Autism Spectrum Disorder in Adolescence and Adulthood. A Case Series (Keller et al., 2015)^[33]Recognizing Psychosis in Autism Spectrum Disorder (Ribolsi et al., 2022)

Putting this all together, if you have been diagnosed with psychosis but you relate to many autistic traits, especially if you’ve had these traits your entire life, it may be worth seeing whether you may be autistic instead of or in addition to psychosis!

Do autistic and psychotic traits exist on the same spectrum?

Some research theorizes that autistic traits—like our social communication and sensory perception differences—and psychosis are actually two presentations of the same traits but on opposite ends of the spectrum.^[34]Psychosocial functioning in the balance between autism and psychosis: evidence from three populations (Abu-Akel et al., 2022^[35]The interactive effect of autism and psychosis severity on theory of mind and functioning in schizophrenia (Vaskinn & Abu-Akel, 2019) This line of research even finds that individuals who have prevalent autistic traits and psychotic traits face fewer challenges in day-to-day life. These characteristics seem to “cancel out” in a way. This may also explain why there is a high degree of genetic and neurobiological overlap between these two groups.

For those of you who are autistic and experience psychosis, does this resonate with your lived experiences?

This interesting perspective makes me wonder if the reason autism and psychosis are so often lumped together is because both identities fail to fit in with the neurotypical way of perceiving the world. Perhaps misdiagnoses and co-occurrence are both common because we are two versions of neurodivergent and nonconforming traits related to perception.

Summary

• Psychosis is a common occurrence in autism.
• Many autistic traits also resemble psychotic traits, leading to some individuals being diagnosed with psychosis-related conditions instead of autism or instead of autism + psychosis.

If you would like to learn about what it’s like to experience psychosis as an autistic, check out Eva’s experience of psychosis.